Friday, August 11, 2023

Foreign accent syndrome 4

Broderick A, Labriola MK, Shore N, et al. Foreign accent syndrome as a heralding manifestation of transformation to small cell neuroendocrine prostate cancer. BMJ Case Reports CP 2023;16:e251655.


A man in his 50s with metastatic hormone-sensitive prostate cancer, receiving androgen deprivation therapy and abiraterone acetate/prednisone, presented with an uncontrollable ‘Irish brogue’ accent despite no Irish background, consistent with foreign accent syndrome (FAS). He had no neurological examination abnormalities, psychiatric history or MRI of the brain abnormalities at symptom onset. Imaging revealed progression of his prostate cancer, despite undetectable prostate-specific antigen levels. Biopsy confirmed transformation to small cell neuroendocrine prostate cancer (NEPC). Despite chemotherapy, his NEPC progressed resulting in multifocal brain metastases and a likely paraneoplastic ascending paralysis leading to his death. We report FAS as the presenting manifestation of transformation to small cell NEPC, a previously undescribed phenomenon. His presentation was most consistent with an underlying paraneoplastic neurological disorder (PND), despite a negative serum paraneoplastic panel. This report enhances the minimal existing literature on FAS and PNDs associated with transformed NEPC.

Key Takeaways

Recently, a man suddenly woke up with an Irish accent after being diagnosed with cancer.

Foreign accent syndrome is a rare disorder that can be caused by tumors, brain injury, and other conditions.

A full medical care team will usually be needed to help a patient with foreign accent syndrome.

Imagine suddenly speaking with an accent that sounds like you were born and raised in, say, Italy or Jamaica. That’s what happens to patients with foreign accent syndrome (FAS), a rare condition that researchers are striving to better understand.

In a recent report of FAS published in BMJ Case Reports, researchers out of Duke University in Durham, North Carolina, and Carolina Urologic Research Center in South Carolina shared the story of a man in his 50s who developed the syndrome after a cancer diagnosis.

The individual in the case report was diagnosed with metastatic hormone-sensitive prostate cancer. Twenty months after his diagnosis, he developed “an uncontrollable ‘Irish brogue’ accent despite no Irish background,” according to the report’s authors. The man had never been to Ireland and had never spoken with an Irish accent prior to this point.

“He had no neurological examination abnormalities, psychiatric history, or MRI of the brain abnormalities at symptom onset,” the report stated.

What is foreign accent syndrome?

Foreign accent syndrome is real, although it’s rare. According to the Callier Center for Communication Disorders at the University of Texas at Dallas, FAS (which has also been referred to as pseudo-FAS and dysprosody) is a speech disorder that causes a sudden change to a person’s speaking speech patterns.

The onset of FAS can be sudden or gradual. “In [the case of the man in the report], it developed over days but worsened. It can be very quick,” Andrew J. Armstrong, MD, MSc, and Medical Oncologist at Duke Cancer Center, tells

The first case of FAS was reported in 1907. Since, there have been around 112 known cases, with FAS affecting people in multiple countries and in multiple ways. The accents in FAS are all over the spectrum, with people whose American accents became Caribbean or whose Japanese accents became Chinese.

FAS patients’ accents are perceived as “foreign,” largely due to changes in the “timing, intonation, and tongue placement” of the speaker. For example, some FAS patients may put stress on different syllables, while others have trouble pronouncing consonants clearly.

So when people with FAS speak in a French or Irish accent, for example, it’s not really French or Irish. “Although it is called foreign accent syndrome, the accents heard are not true accents of any specific language. Instead, they tend to sound like a mix of different accents or dialects,” says Nick Bach, PsyD.

The causes of FAS

“Stroke, trauma, brain tumors, and psychiatric conditions [are the main causes] of FAS,” says Armstrong. Cases of FAS have also been reported in psychiatry, in cases of mania, bipolar disorder, and schizophrenia, among other conditions. The researchers believe that paraneoplastic neurological disorder (PND)—effects caused by systemic malignancies that impact the nervous system—was ultimately the cause of FAS in the case report's individual. “The term PND is reserved for those disorders that are caused by an autoimmune response directed against antigens common to the tumor and nerve cells,” according to the Journal of Neurology, Neurosurgery & Psychiatry. According to the report, the patient’s biopsy revealed small-cell neuroendocrine prostate cancer (NEPC), which progressed despite treatment and led to multifocal brain metastases and paraneoplastic ascending paralysis.

The report suggests that this was the first case of FAS found in a patient with prostate cancer but the third case in a patient with malignancy.

“We have no other clear explanation other than a paraneoplastic syndrome given the timing, persistence of symptoms, lack of psychiatric conditions or metastases or lesions in the brain at the time of onset,” says Armstrong. “We provide this report in case future patients may be identified and hopefully a specific antibody may be identified to better explain why this happened.”

Treating FAS and supporting patients

Diagnosis of FAS will require testing your patient’s language skills and recording their speech patterns, as well as EEG, MRI, PT, CT, or PET scans. Treating the underlying issue—whether that be a neurological disorder or a tumor, for example—is the recommended form of treatment, Armstrong says. Treating FAS takes a village, and would ideally include a speech-language pathologist, a neurologist, a radiologist, a neuropsychologist, and a psychologist. Some cases of FAS have resolved without intervention, while others evolve or remain, according to ASHAWire.

While medical treatment is key, treating the psychological impact of FAS is also necessary, as developing a new accent can cause a loss of identity.Reader TMP. ‘I’ve lost my identity’: on the mysteries of foreign accent syndrome. The MIT Press Reader. Some patients say they’ve also faced discrimination when speaking in public or being accused of faking their accents.

Psychologists play a part in the care team

“When a patient has developed FAS, psychologists can help treat them in a number of ways,” Bach says.

“This may involve helping them to develop new communication strategies or to understand and accept the changes to their speech. Additionally, psychologists can also provide support and guidance to patients as they navigate challenges such as social isolation or discrimination."

“By working with a psychologist, patients with FAS can receive the specialized care and support they need to manage their condition.”

Bach advises MDs who may work with a FAS patient to have compassion. “I believe that it is essential for medical professionals to be able to understand the unique challenges that patients with FAS face,” Bach says.

“I think that developing a supportive relationship with patients is key in helping them manage their condition.”

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